Minutes of a Formal Meeting held in Public of the Governing Bodies of NHS Brighton and Hove (B&H) and NHS High Weald Lewes Havens

(HWLH) Clinical Commissioning Groups (CCGs) held together on Wednesday 2 October 2019, from 9.30am, Ralli Hall, 81 Denmark Villas, Hove, BN3 3TH

Present: NHS Brighton and Hove (B&H) CCGDr Andrew Hodson, Executive Clinical Director (AHo)Dr David Supple, Clinical Chair (DS)Allison Cannon, Chief Nursing Officer (AC)Christopher Adcock, Chief Finance Officer (CA)Jennifer Oates, Independent Clinician, Registered Nurse (JO)Karen Breen, Deputy Chief Executive Officer / Chief Operating Officer (KB)Lola Banjoko, Managing Director (LB)Malcolm Dennett, Lay Member for Governance (MD)Rob Persey, Executive Director, Health & Adult Social Care, B&H City Council (RP)NHS High Weald Lewes Havens (HWLH) CCGChristopher Adcock, Chief Finance Officer (CA)Denise Matthams, Independent Clinician, Registered Nurse (DM)Dr David Roche, Locality Lead (High Weald) (DR)Dr Elizabeth Gill, Clinical Chair and Convening Chair (EG)Frank Powell Locality Practice Management Lead, High Weald (from 9.44) (FP)Karen Breen, Deputy Chief Executive Officer / Chief Operating Officer (KB)Martin Smits, Lay Member for Primary Care Governance (MS)Dr Naomi Forder, Independent Secondary Care Consultant (NF)Dr Peter Birtles, Clinical Programme Lead, Primary & Urgent Care (PB)Peter Douglas, Lay Member for Governance (PD)Dr Ragu Rajan, Clinical Programme Lead, Planned Care (RR)Dr Sarah Richards, Chief of Clinical Quality and Performance (SR)

Inattendance:

David Cryer, Executive Director of Strategy (from 9.47) (DC)Hugo Luck, Deputy Director of Primary & Community Care (from 10.55 to 11.41) (HL)James Hatch, Engagement Officer (JH)Lisa Hopkinson, Senior Governance Officer, South Place (Minutes) (LH)Moosa Patel, Interim Associate Director of Corporate Affairs, (NHS Coastal West Sussex CCG) (MP)Naomi Hicks, Senior Administrative Officer (until 10.15) (NH)Nicky Cambridge, Director of Equality, Diversity & Inclusion (from 10.30 to 11.20) (NC)Terry Willows, Executive Director of Corporate Governance (TW)Tom Gurney, Executive Director of Communications and Engagement (TG)Wendy Carberry, Executive Director of Primary Care (until 10.55) (WC)

Item No.

Item Action

16 Meeting Opening Items

16.1 Welcome, apologies, and confirmation of quoracy

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The Convening Chair (EG) welcomed everyone to the Governing Bodies in Common meeting and in particular welcomed members of the public who were observing the meeting.

Apologies had been received from:

Adam Doyle, Chief Executive Officer (AD) Alan Keys, Lay Member for Patient and Public Engagement (NHS HWLH

CCG)(AK) Alistair Hill, Director of Public Health Brighton and Hove City Council (NHS

B&H CCG) (AHi) Dr Charles Turton, Independent Clinician, Secondary Care (NHS BH CCG)

(CT) Dr Jim Graham, Local Cluster Representative (NHS BH CCG) (JG) Jonathan Molyneux, Lay Member for Finance (NHS BH CCG) (JM) Joanne Bernhaut, Public Health Consultant East Sussex County Council

(JB) Karen Ford, Locality Practice Management Lead, Lewes Havens (NHS

HWLH CCG) (KF) Mike Holdgate, Deputy Chair of CCG and Lay Member for Patient and

Public Engagement (NHS BH CCG) (MH) Dr Neil Myers, Locality Lead (Lewes Havens) (NHS HWLH CCG) (NM) Dr Tom Gayton, Local Cluster Representative (NHS BH CCG) (TGa)

Notwithstanding the noted apologies, it was agreed that the meeting for NHS HWLH CCG was quorate.

However, for B&H CCG, quoracy was not attained and, knowing this, Dr Tom Gayton had reviewed the papers in advance of this meeting, and had sent written approval of agenda items 16.4, 17.2, 17.3, 17.5, 20.3 and 21.2. Any items for which voting was required and where TGa’s approval was still needed would be taken back to TGa post-meeting and, if any decision by him differed from that of those in the meeting, the Governing Bodies would be informed.

16.2 Declaration of any Conflicts of Interest

The Governing Bodies noted that there were no new Declarations of Interest (DOI) and that there were no previously declared interests considered prejudicial to any of the agenda items that day.

Clinical Directors of the Primary Care Networks were asked to declare any interests as they became known during items on the agenda.

16.3 Questions Submitted by the Public

Questions from the public were taken prior to the formal opening of the meeting. A record of the discussion was appended to these minutes – please see Appendix A.

16.3.1 Integration Training: This item was read out by the author and a verbal update was provided to this which would be sent to the author within a week of the meeting.

ACTION: TW to arrange written response to be sent to author.

16.3.2 This item was read out by the author and Dr David Supple replied from the written response that was provided to the author at the meeting. The author indicated that there were changes proposed by NHS England (NHSE) that may allay the concerns contained in these questions.

16.3.3 Question withdrawn by author

16.3.4 The petition was read out by one of the group members and Dr David

TW 9 Oct 19

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Supple read out the response collated by the CCG. DS advised the Governing Body and the author that this response was prepared to answer the initial petition statement but that a revised petition statement had been received very recently; it was deemed however that the original response still addressed the points raised in the revised petition but that a discussion on the revised petition could not be held during this meeting. DS offered to arrange a meeting with the action group, if they wished to do this.

16.4 Draft minutes of previous meeting held on 7 August 2019 for approval

The minutes of the 7 August 2019 NHS B&H and NHS HWLH CCGs Governing Bodies’ meeting together were approved as an accurate record of the meeting without amendment.

16.5 Action Log and Matters Arising

The Governing Bodies reviewed the Action Log and agreed that the following actions were updated as follows:16: 4.1 Commissioning Reform: TW to ensure the Implementation Plan was brought back to the next GB meeting.This had been an ongoing piece of work and was on the agenda of this meeting. Agreed this could now be closed.

19: 5.1 Board Assurance Framework (BAF) and Organisational Scorecard: Ensure a revised Boardbook was uploaded to the website with the corrected Board Assurance Framework and Organisational Scorecard reports for NHS B&H CCG.The BAF paper on today’s agenda had corrected the position and the action would be completed later this week. Remained open for now.

23: 7.5 Matters for Delegation to the Governing Bodies’ Committees: A decision needed to be reached as to which committee(s) would receive updates on items 6.3 (Staff Survey Results) and 6.4 (360 Degree Stakeholder Survey Results) later in the year.There was a proposal to bring the issue to the November Governing Bodies (GB) Seminar and for the outcomes to be brought to the December formal GB meeting. Remains open until presented.

29: 12.3 Clinically Effective Commissioning Update: Update required on the current position with patient flows and future ways of working with the Kent PCNs and with MTW. Contact the Managing Director (North Place) to ascertain how we could be clearer about the relationship with Kent trusts.A progress report on this would be written and would come back to the GBs as an update – the action was therefore closed.

30: 13.1.3 Report from Audit and Risk Committees: ALL GBs members to send a list of any potential gaps in assurance that they have identified around PPE and E&D to AK and MH for them to collage and forward on to TGu.A full report was presented and discussed at Audit Committee (AC) last week and an action plan had been developed. Action was closed.

32: 13.4 Annual Report on Patient and Public Engagement (PPE): How the governance of PPE within the new structure may look and how the CCGs would articulate to the public how and where their voice could influence the work that the CCGs undertake.A meeting was due to take place on 3 October 2019 to discuss these issues. It was noted that whilst neither Lay Member for PPE was available to attend, TGu had met

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with them both and their views would be represented by him. Action was closed.Action Log to be updated with the above progress.

The Governing Bodies approved the update on matters arising and recommendations for closure of actions.

16.6 Chief Nurse Patient Story

Allison Cannon conveyed a story about an elderly individual who was a carer for their spouse but who also was a cancer survivor. This patient had visited their GP quite distressed due to the pressure they were under and the isolation they felt as they had previously been very active. The GP referred this person to the local social prescribing workers who spoke at length with this person about what interested them and what they would like to do. Further referrals were made in an attempt to address the isolation issues and the individual became more active with volunteering within support groups, providing talks on their experiences and promoting health and wellbeing for cancer patients.

AC concluded that this story demonstrated that there was work being carried out within the community integration of health and social care that was an important feature within the NHS Long Term Plan (LTP). It also highlighted the care and compassion that staff have for ensuring the patients in their care are looked after in an appropriate and holistic manner.

16.7 Reports from the Clinical Chairs

Elizabeth Gill presented this report and highlighted the key issues:

Constitutional changes: Constructive discussions had been happening in both CCGs

Clinical engagement was underway

Mental Health Liaison Workshop – this was held on 24 September 2019 and had good and wide ranging attendance

Chairs and Non-Executive Director’s (NED) Forum had been held with a further one planned in January 2020. There was a discussion at this forum as to how many forums would be appropriate and at that stage, it initial thoughts were that three would be needed but that had not yet been agreed.

EG brought attention that this report had a supplementary ‘Independent Chair Update’ appended to it which heighted the challenges that lay ahead.

There were no questions raised on this report and the assurance was received from it.

16.8 Chief Executive Officer’s Report

Karen Breen presented this briefing on behalf of Adam Doyle. The report was taken as read however KB wished to draw attention to the following:

Dr David Supple was standing down as Clinical Chair for NHS Brighton and Hove (B&H) CCG following this meeting and Dr Andrew Hodson would be taking on this role from 17 October 2019. KB wished to extend thanks from Adam Doyle and the Executive team to DS for all the dedication, hard work and support he has given to the CCG over his time in office

Lola Banjoko was formally welcomed into her substantive post of Managing Director

The importance of the Chief Medical Officer (CMO) role was raised and that interviews for this post were to be held on 18 October 2019

Terry Willows had been appointed as Accountable Emergency Officer on top

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of his substantive post of Executive Director of Corporate Governance and KB extended congratulations to him

As much of the content of this report was on the agenda, nothing further was discussed and questions were invited; there were none.

The Governing Bodies confirmed they were assured by the report.

17 Strategy and Transformation

17.1 Commissioning Reform

David Cryer presented this paper which was for assurance and highlighted a number of key points:

A number of GB decisions had been made around the merger of some of the CCGs

The Transition Steering Group met on 3 September and again on 1 October 2019

The Operating Model, Leadership Model and staff structures were agreed and went out to staff consultation on 1 October 2019. Staff should start to move into the new posts from late November 2019

Local Management Teams would take a greater role from early November; this would be a gradual transition

The transition for NHS East Surrey CCG into Surrey Heartlands Health and Care Partnership would be from 1 November 2019, as per the plan.

Comments and questions were invited:

It was noted that the Programme Steering Group appeared to be light on Lay membership, particularly for HWLH.Denise Matthams was to be the Lay representation for HWLH however, it was expected that a full list of the membership would be presented at the next GB meeting.

The Governing Bodies were asked to note the progress of the Commissioning Reform Programme and the role of the Steering Group and this was noted.

17.2 Approval of New CCG Constitutions

Terry Willows presented this report which was for approval, on the basis that there would be more consultation with the memberships around the constitutions.

TW explained the purpose of each document in the annexes and where the known gaps were and confirmed that the constitutions were based on an NHSE model constitution.

The Governance Handbook was a public-facing document that explained how the governance works and how the CCGs work with their memberships; it was noted that this will always be a live document as it would constantly be changing.

TW highlighted that the Scheme of Reservation and Delegation (Annex G) sets out the matters which were reserved for the GB, those that were delegated to the committees, and those delegated to specific officers. It was important to recognise that the Scheme of Reservation and Delegation also sets out the matters that should be referred to the memberships. It stated that changes must be made through the GB and would ensure that membership approval is sought where appropriate.

It was further highlighted that there were some items still missing from the suite of documents and these were (1) a map and the number of localities that would be included within each CCG and (2) details as to how those localities would work and how they would be supported by the CCGs. There were plans to discuss these issues with the localities over the next few weeks.

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[RP left the meeting and NC joined the meeting at 10.30]

If the GBs agreed what was being asked of them (twelve points were listed in the paper) then the process of detailed conversations with the localities would begin.

ACTION: TW to circulate the pack to GB members for comments ahead of it going out to the membership.

Questions and comments were invited and were considered specific to each CCG:

NHS HWLH CCG Views:

There was initial suspicion from one locality however the Locality Lead felt, having heard from TW now, that they would be reassured regarding their representation.

There was a further issue around the East Sussex border as noted in the draft Constitution; specifically that if a service was provided just over the border in Kent that Sussex residents may be excluded from using that service. It was noted that this had been addressed in the outgoing constitution but not in the proposed document and the request was that it was addressed again. It was impressed upon the GB that the membership would certainly seek assurance around this matter

EG advised that a colleague in a different locality had emailed in support of the actions in the report and the suggested way forward, as they were unable to attend this meeting

Something more definitive was desired around the look and function of the localities

Confirmation was requested on the number of representatives from localities who would sit on the GB as this had differed between communications

It was noted from the draft Constitution document that items reserved for the membership required a 75% approval; this could be difficult to achieve and this would provide the CCGs with a challenge to engage with the membership. However, it was possibly a good method of engaging with the membership and it was proposed that additional issues might be reserved for the membership in this manner

The GB heard that some GPs do not see the difference between commissioning and providing in the same way that the GB did

TW addressed some of these points as follows:

Border Issues: Clarity would be incorporated into the documents as to how the CCGs will work with partners across borders

Localities: The proposals for East Sussex were that there would be nine Locality Representatives initially, with it reducing to eight later. This would be made clearer in the next iteration of the documents

Membership Threshold (75%): CCGs should be trying to engage with their membership around decision-making and this suggestion could be a way of doing that. Paragraph 2.4.8 of the Standing Orders states that there is a provision that any decision of the membership was usually by a simple majority but the GB had the ability to set a higher threshold for that membership endorsement. There was a protection in the document that gave the GBs the authority to change the threshold on an issue if it warranted it; such an example could be if the Locality Representative felt

TW11 Oct 19

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unable to endorse an issue on their locality’s behalf

WC addressed the final point made; there was a discussion due to start at an event on 3 October 2019 with Clinical Directors around what the localities and Primary Care Networks (PCN) may look like.

EG thanks all those involved in discussions over the last months. The HWLH GB was asked to approve the pack of documents and agree that the pack should be circulated to GB members before it went to the membership; the vote took place and was unanimous in its agreement.

ACTION: TW to circulate the proposals for the localities to the GB post-meeting ahead of these going to the membership.

NHS B&H CCG Views:

It was noted that there had been a good discussion at the Locality Meeting with the membership and it was perceived that B&H had lacked some engagement with the membership in the past. There was broad support for some of the new roles such as that of the Vice-chair.

TW replied that the Locality Meeting on 12 November 2019 was the target date for conversations around this issue to have concluded so the revised documents could be put to the membership.

DS asked the B&H GB members to vote on the same proposals as the HWLH GB had done; this vote was also unanimous in its agreement.

Both CCGs approved without exception the recommendations put to them.

[WC left the meeting and HL joined the meeting at 10.55]

TW11 Oct 19

17.3 Response to the NHS Long Term Plan (LTP)

David Cryer presented the paper which set out the further progress and achievements made in the planning and delivery of the Sussex Strategic Plan. The paper was for noting the process and not to approve the plan itself.

DC advised that there will be a further opportunity in the November Seminar to obtain more detailed information on this and to provide input. There were a few areas recognised as needing more work however and these were:

Language: The wording around the PCNs, their roles and the care setting needs further work to make it clearer and easier to understand

Prevention: A greater focus needs to be given in the report around this topic and the work already undertaken by Public Health

Specialist Commissioning: Recognition of this and how it will operate needs to be incorporated.

The Governing Bodies noted the progress made in developing the Sussex Strategic Plan.

17.4 Primary Care Networks Development Update

David Cryer presented this item on behalf of Wendy Carberry, which was for assurance. The key points to note were:

The Network agreements had all been signed

There had been a number of sessions this week where the Clinical Directors

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and the PCNs got together and another session is planned for 26 November 2019 where the Clinical Directors would meet with providers; one of the topics for discussion here would be around how PCNs were best represented within Integrated Care Partnerships (ICP)

PB stated that the meeting on 1 October 2019 in West Sussex (incorporating NHS Coastal West Sussex CCG, NHS Crawley CCG and NHS Horsham and Mid Sussex CCG) went well and the meeting on 3 October 2019 which PB was to facilitate was for East Sussex (incorporating NHS Eastbourne Hailsham & Seaford CCG, NHS Hastings & Rother CCG and NHS HWLH CCG) and NHS B&H CCG

An issue that came out of some of the above mentioned meetings was that some PCNs ‘feel’ they are being asked to do everything but PB and the GBs were clear that this was not the case and thus communications needed to be improved in order to rectify this misconception

The focus of PCNs was to deliver personalised local care and deliver the content of the LTP

There were no other comments or questions raised. The GBs noted and were assured on the progress made across Sussex with respect to PCNs.

17.5 Inclusion Strategy

KB 6 Nov 2019

DS/AH

Allison Cannon presented this report which was for approval. The Governing Bodies were asked to note the ongoing progress and to recognise that the strategy will evolve further over the coming months.

Nicky Cambridge advised that a six monthly progress report would come back to the GBs.

Questions and comments were invited:

NC and AC were asked to advise the GBs what the expectations were of them around this strategy and how they might champion it. The response included the incorporation of the inclusion agenda in the issues that were raised at GB meetings, including the constitutional issues

NC was asked where she felt the main risks around the delivery of this strategy were and what might be difficult to address. NC advised that a risk around the existing workforce delivering on the Staff Ambassador roles was a risk but under the new Operating Model resources had been made available to support this work. Furthermore, it was felt that the section on ‘Equality, Diversity and Health Inequalities’ on the report cover sheet was helpful. It was noted that an improvement plan was in place to address the concerns raised.

[RP re-joined the meeting at 11.11]

There were concerns that some groups did not fall into protected characteristics and thus how were they being helped; however the committee was informed that if any patient group was identified as not being addressed within the current classifications, this would be addressed as they arose. The issue of 16-18 year olds being unable to access some services (due to a gap in service provision for this age group) was raised and NC confirmed that, if they had been identified, they should already be being addressed within the Inclusion Programme.

ACTION: KB was to undertake a review of services for 16 – 18 year olds and feedback to the GB on her findings.

[NC left the meeting at 11.20]

ACTION: DS/AH to follow up on the point raised that there was no Lay person for

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Inclusion on the GB and wondered if going forward, there should be.

The GBs approved the strategy.

6 Nov 2019

COMFORT BREAK17.6 Update on the Lewes Urgent Treatment Centre (UTC) Development

Hugo Luck presented this late item which was for assurance by NHS HWLH CCG.

The GB was advised that, in order to redevelop the site at Lewes Victoria Hospital in to a UTC, a decant was required in order to allow the works to happen to create additional space for treatment rooms. Procurement of contractors is ongoing but is at the commercially sensitive stage and so would not be discussed at this forum; however works were expected to comment late in November or early in December 2019. Full impact assessments had been carried out and were appended to the paper.

It was felt that the impact on temporarily locating services elsewhere would be minimal as January/February was generally a quiet time for Minor Injury Units (MIU); however contingency plans were still being implemented where necessary. There was no expectation of a reduction in capacity as services such as x-ray would move to Uckfield and ‘NHS 111’ bookings into Uckfield and Crowborough hospitals had been prioritised.

HL assured the GB that every step had been taken to minimise disruption to both patients and staff and explained that the CCGs were in discussion with SCFT regarding what additional services could be placed in the hospitals in Uckfield and Crowborough. Clarity was given that these services would be both for ‘walk in’ patients and for those referred by ‘NHS 111’.

EG thanked all the staff involved as it was recognised that an enormous amount of work had been undertaken over a number of years.

The HWLH GB:

Noted the progress towards the development of an Urgent Treatment Centre (UTC) in Lewes Noted the need for a decant of services to Uckfield Community hospital during the duration of the building works Was assured that plans have received appropriate scrutiny/governance by the CCG.

[HL left the meeting at 11.41]

18 Board Assurance Framework

18.1 Board Assurance Framework and Organisational Scorecard

Terry Willows presented this item which was for assurance.The Audit Committees had met last week and recommended that the GBs continued to use the existing Risk Appetite Statement until the end of the financial year.

The balanced scorecard provided an excellent overview of the risk situation.

The GBs were assured by this report.

18.2 New NHS Oversight Framework 2019/20

Terry Willows presented this item which was for assurance.

NHSE and NHS Improvement (NHSI) were working together on this item to regulate and assure the local NHS as one organisation. The key points raised were:

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The role of system leadership was described in the document in that it addressed issues that arose in each system by providing the required oversight and assurance. There was a potential however for a conflict of interest as Adam Doyle was the Senior Responsible Officer (SRO) across the entire system as well as the Chief Executive Officer for the CCGs; however, it was noted that Karen Breen would step in when a conflict of interest arose

NHSE still needed to provide a leadership rating later this year.

The GBs were assured by this report.

19 Committee Reports

19.1 Governing Body Committee Reports

19.1.1 Report from Finance and Performance Committees (F&P)

Martin Smits presented the Finance & Performance Committees in Common report, which was for assurance, for both CCGs and outlined the following key points:

There was an unmitigated risk gap of £3.4m at the last meeting however this had reduced to £2m; furthermore there were no red risks remaining. Work was continuing to reduce this gap. NHSE were assured by this and no longer insisted on a monthly report

Prescribing expenditure challenges remained and a detailed report on this had been requested for the October F&P meeting

There was assurance that the concerns around cancer performance were starting to be addressed.

There were no comments or questions raised.

EG thanked MS and JM for their report; the Governing Bodies were assured by this report.

19.1.2 Report from Quality and Safety Committees

Jennifer Oates presented the report from the Quality and Safety Committees in Common, which was for assurance, and addressed some important themes, although many had already been discussed in previous items:

Concern had been raised regarding the governance and scrutiny of Patient and Public Engagement. Both Lay members had concerns due to the lack of opportunity to discuss issues or raise concerns. It had been agreed that this would be discussed outside the meeting with Tom Gurney

There was pressure on the Director of Nursing around the Transforming Care Partnership (TCP) programme as to why the CCGs were not where they needed to be in terms of patient discharges. There were several reasons for this, which included the identification of new cohorts of patients by Sussex Partnership Foundation Trust (SPFT) and the lack of suitable accommodation to transfer these patients into, post discharge from hospita.

The committees had been overwhelmed by the size of the agenda. There was a meeting immediately following the GB meeting to discuss how this could be addressed and how the new structure may facilitate different ways of working. This was to be fed back at the next GB meeting.

ACTION: JO/DM to ensure their next report included an update on the progress around the size of the Quality and Safety Committees’ (QaSC) agenda.

There were no comments or questions raised.

JO/DM4 Dec 19

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EG thanked JO for the report; the Governing Bodies were assured by this report.

19.1.3 Report from Audit Committees

Malcolm Dennett provided a verbal update as the last Audit Committees in Common meeting was held only last week. There were three points raised:

There were a number of Internal Audit actions overdue that were still awaiting a resolution and these were a concern to the Audit Committees. This included an Audit Report that remained unapproved. Further updates to these actions had been requested from the Executive Directors before the next Audit Committees’ meeting in December

A report on the External Governance Reviews of all the CCGs in Sussex and East Surrey had been received and a detailed action plan had been compiled and addressed and was considered closed

The PPE issue flagged in the QaSC Chairs’ Report was also discussed at the meeting last week, where both Lay members for PPE attended. The committees received an action plan and there was a recommendation for more work to be undertaken around this.

There were no comments or questions raised.

EG thanked MD for the report; the Governing Bodies were assured by this report.

19.1.4 Report from Primary Care Commissioning Committees

a. B&H CCG: Jennifer Oates presented this report, which was for assurance, on behalf of Charles Turton and shared the following key points:

There was public enthusiasm for more public representation on CCG committees

It was unclear how to monitor how the public voice may have influence over the Primary Care Strategy.

b. HWLH CCG: Martin Smits advised he wished the GB to note the contribution that the LMC made within the PCCC and thanked Dr Karthiga Gengartharan for her valuable contribution as she was leaving due to moving to another area.

There were no comments or questions raised.

EG thanked CT, JO and MS for the reports; the Governing Bodies were assured by this report.

19.1.6 Report from HWLH Clinical Executive Committee (CEC)

Dr Sarah Richards presented this report which was for assurance, and was taken as read. She added that it covered the meetings held in July and August 2019 but that content from the September meeting would come to the next GB due to the timing of it.

There were no comments or questions raised.

EG thanked SR for the report; the Governing Body was assured by this report.

19.1.7 Report from B&H Clinical Commissioning Committee

Andrew Hodson presented this report, which was for assurance, and raised the following key point from the August meeting:

There had been a good update on the cancer position and this was reflected in the discussion at the Locality meeting around what Brighton and Sussex Universities Hospitals NHS Trust (BSUH) was doing to improve the care for

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patients there.

There were no comments or questions raised.

EG thanked DS for the report; the Governing Body was assured by this report.

19.2 Matters for Delegation to the Governing Body Committees (as required)

Item 16.4 – Action Log

23: 7.5 Matters for Delegation to the Governing Body Committees: A decision needed to be reached as to which committee(s) would receive updates on items 6.3 (Staff Survey Results) and 6.4 (360 Degree Stakeholder Survey Results) later in the year.There was a proposal to bring the issue to the November Governing Bodies (GB) Seminar and for the outcomes to be brought to the December formal GB meeting.

20 For Assurance

20.1 Integrated Contracts, Performance and Quality Report

Chris Adcock presented this item which was for assurance. The Governing Bodies noted that the actions had been made clearer since the last report, but it was known further work was still required.

Since the report was written the position had changed slightly and the Governing Bodies were advised of the following:

IAPT: The report stated the procurement was complete however whilst it had been approved, it was not yet concluded

Memory Assessment Service: There was a proposal to have a joint service with NHS HWLH CCG and the two East Sussex CCGs and further work had been identified around this procurement

Dementia Diagnosis Rate: Further work had been identified as being necessary; actions around the waiting list had made a difference but August was still below trajectory.The delivery of the October target and the current forecast was that the CCGs would recover the position by December; however there remained a reliance on locum staff

Referral to Treatment (RTT): This remained below target although activity had increased in July. The trusts had submitted a revised plan to the regulators

62 Day Cancer Target: There was confidence that this would be delivered by December 2019. Diagnosis rates were reducing but were still above the national average.

Comments and questions were invited but there were none.

The GBs were assured by this report.

20.2 Finance Report

Chris Adcock presented this report which was for assurance.

The GBs heard that the position for HWLH had already been described and CA remained confident that ongoing work to mitigate the risks would deliver the control total.

NHS B&H CCG continues to report strong financial performance; a detailed review was being carried out on all the Sussex CCGs and a watch was being maintained on prescribing financial pressures.

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Comments and questions were invited, however none were raised.

EG thanked CA for the report; the Governing Bodies were assured by this report.

20.3 Local System Winter Plans

Lola Banjoko presented this paper which was for assurance, feedback and to note.

The Governing Bodies heard that the report outlined the system-wide approach taken by the BSUH Local A&E Delivery Board (LAEDB) in order to ensure that the system was able to effectively manage the capacity and demand pressures anticipated during the winter period; lessons had been taken from previous years and perspectives from quality and PPE have been incorporated.

Comments and questions were invited:

There would be a need to watch for any potential impact on services around RTT

It was perceived that some of the issues such as delayed transfers of care (DTOC) reaching 2.5% may be unachievable. RP explained that this should state that the 2.5% was an ‘ambition’ however if the wording did not reflect this; it should be amended. The Governing Bodies heard that the national target was 3.5% which was what the CCGs signed up to.

ACTION: LB to ascertain the correct wording around DTOC and ensure this was correctly reflected in the document.

ACTION: LB to ensure that the assurance around reaching the 3.5% or 2.5% target was made clear.

EG thanked LB for the report; the Governing Bodies were assured by this report.

LB 11 Oct 19LB 11 Oct 19

20.4 NHS 111 Contract Award and Mobilisation

Lola Banjoko presented this paper which had been through the F&P Committees.

The Governing Bodies were asked to note the status of the procurement award for the NHS111/Clinical Assessment Service (CAS) and be assured of the contract award process followed by the Sussex, Kent and Medway Joint Committee in accordance with their delegated responsibility.

The GBs noted that assurance on the mobilisation process will come to the GBs via the F&P Committees.

MD stated that the Audit Committees were satisfied on this process but wanted to point out that there were three concerns, these being around workforce, digital aspects, and whether an effective monitoring framework would be implemented.

The GBs were assured by this report.

21 Closing

21.1 Governing Body Forward Planner

This item was to note. No comments or questions on its contents were raised.

21.2 Any Other Business (to be notified to Chair at least two working days in advance)

There were no items raised, however EG wished to thank David Supple, on behalf of the GB members and the Executive Team, for all his hard work, support and advice to NHS B&H CCG and its GB, and also in the process of working well together with NHS HWLH CCG.

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21.3 Evaluation of Meeting Performance

No comments were raised.

Meeting Closed at 12:20

Date of Next Meeting

6 November 2019 (Seminar) 09.00 – 13.00 - Main Hall, Ralli Hall, Hove, BN3 3TH

4 December 2019 (Formal) 09.30 – 13.30 - White Hart Hotel, 55 High St, Lewes BN7 1XE

8 January 2020 (Seminar) 09.00 – 13.00 - Boardroom, Friars Walk, Lewes, BN7 2PB

5 February 2020 (Formal) 09.30 – 13.30 - Main Hall, Ralli Hall, Hove, BN3 3TH

4 March 2020 (Seminar) 09.00 – 13.00 - Boardroom, Friars Walk, Lewes, BN7 2PB

Resolution of items to be heard in privateThe motion was carried that “In accordance with the provisions of Section 1(2) of the Public Bodies (Admission to Meetings) Act 1960, it was resolved that the representatives of the press and other members of the public were excluded from the second part of the Governing Body meeting on the grounds that it was prejudicial to the public interest due to the confidential nature of the business about to be transacted. This section of the meeting would be held in private.”

Freedom of Information Act: Those present at the meeting should be aware that their names and designation would be listed in the minutes of this Meeting, which may be released to members of the public on request.

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Appendix A Governing Body Questions

Presented to the Governing Bodies meeting in Common on 2 October 2019

Item 16.3.1

Question: Integration Training for CCGs

I was particularly concerned to read that NHS England has just awarded a £7million contract to Optum Alliance, which is part of the US company United Health, to train CCG executives how to “integrate” the local health system and make it more like an American “Accountable Care Organisation”, which involves:- itemising costs on a patient-by-patient basis- segmenting the population to identify high cost patient groups (risk stratification)- restricting patients access to treatments in order to cut costsand that these strategies underpin the new Primary Care Networks.

1. Please can you tell me if B&H CCG executives have received or will be receiving training from Optum Alliance?

NHS England commissioned Optum Alliance to deliver the Commissioning Capability Programme (CCP) which is a 12-week leadership development programme for health and social care commissioners. The programme aims to support participants in addressing priority issues currently being experienced across a commissioning system while simultaneously preparing commissioners for the future dynamics of health and care systems particularly in advance of the trend towards integrated care.

The following CCG staff attended this training: the Managing Director, the Director of Commissioning, the Director of Partnerships, the Director of Community, and the Director of System Resilience.

2. If not, is training coming from another provider?Please see the answer to question 1.

3. Do you have concerns about “integration”?4. What evidence do you have that “integration” improves NHS services?

We will respond to your questions 3 and 4 together.

The NHS Long Term Plan is clear regarding the benefits of integration and the part that it plays in delivering improved outcomes where services are integrated around local communities and local ‘places’. The integration of health and social care is therefore a core part of the Sussex Strategic Plan. One of the key themes we hear frequently from our public is how we can improve their experience of care by enabling clinicians, care workers and others involved in their care to work more closely together for the benefit of patients. This is the integration of care for which we are planning.  

We have lots of examples of where we do that very well already across Sussex including:

- the Home First discharge to assess pathway- the Schools Wellbeing Service

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- and the multidisciplinary team working between the Goldstone Primary Care Network, Adult Social Care at Brighton and Hove County Council, and Sussex Community Foundation Trust working together to support those patients who are frail, elderly, or have medium to high mental health needs.

Our local Brighton and Hove response and Sussex Strategic Plan aims to translate these examples of excellent care into the standard that is available to everyone.

Item 16.3.2

Question: Governing Body Questions relating to MSK

Surgery dwindles at major trauma centre as patients opt for private care

This article by Alison Moore, 3rd September, Health Service Journal,

https://www.hsj.co.uk/quality-and-performance/surgery-dwindles-at-major-trauma-centre-as-patients-opt-for-private-care/7025850.article?sm=7025850

exposes the damage Brighton and Hove CCG’s MSK contract is having on our local hospital.

Over the 3 years of the SMSKP contract there has been a shift of elective orthopedic surgery from BSUH to the independent sector – now more than 50% of patients have their surgery in local private hospitals.

The impact of this is loss of income to BSUH, and a reduction in the ability of the hospital to train junior staff: both issues affecting the sustainability of the service and its status as a major trauma centre.

1. Patient choice

How does this work? Is it the patient who makes the choice or is it the MSK staff?

As we confirmed in our previous response, most patients (over 80%) make a decision about provider of surgery before they see a Consultant Orthopaedic surgeon. The choice discussion happens with either a Sussex MSK Partnership Advanced Practitioner (AP) if the patient is seen in a community clinic or a Patient Care Advisor (PCA) if the patient does not require a community clinic assessment.

Less than 20% of patients see a consultant before making a choice decision regarding hospital provider for surgical intervention.  This is normally due to the level of complexity or the need for a second opinion. Complex cases are generally seen in an NHS facility as they are deemed too complex for surgery in a private facility.

During a choice discussion, the AP or PCA will:

Discuss with the patient who the providers are and locations Highlight current waiting times Share details around quality, outcomes, accessibility, parking etc.

The patient is not influenced in any way and they make the decision on where they would like to go for treatment based on the information provided to them.

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There are three situations when MSK staff recommend or make a choice on behalf of the patient:

1. When the MSK service is unable to make contact with the patient to make a choice, the referral is sent to the NHS hospital trust geographically nearest to the patient’s home address. In this situation the patient is written to and advised that if they wish to exercise their right to choose the provider then they should contact the service

2. When a specialist provider e.g. the Royal National Orthopaedic Hospital is thought necessary by the clinician

3. When the patient has clinical complexities, which means they would be excluded from their referral being accepted by certain hospitals.

Does the patient get a letter with a choice of NHS or private hospital?

No. The patient will receive a letter confirming the discussion and their choice of where they will receive treatment.

Does the choosing happen during a consultation?

This usually takes place during a consultation with an AP. Should the patient wish to consider their options, they are entitled to take ‘time out’, which is usually a maximum of two weeks. The patients will then contact the PCA to continue with the referral. We agree that this is a sensible approach when considering something as serious as surgery.

Do phrases like “we usually send our patients to Montefiore, it’s only a two week wait” enhance or contravene patient choice?

We feel that this would contravene patient choice and is not one that is supported by either SMSKP or the CCGs.

How does the CCG monitor patient choice?

We use two methods to monitor patient choice conversations. These are:

Following each consultation, the patient is encouraged to complete a short feedback form. This is done away from the clinician, so feedback cannot be influenced

Annual notes audits are carried out to ensure that notes contain evidence where shared decision-making and choice conversations have taken place. The audit is then used as part of individual and team development.

Any issues raised via either of these routes would get reported via the quarterly quality report and discussed at the contract meetings with SMSKP.

SMSKP are leaders in the field of shared decision-making and as such have recently won a HSJ award for their innovative approach to it. The successes of this are also reflected in their outcomes and performance monitoring.

 2. Competition

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As fewer patients are “choosing” to have their surgery at BSUH, the trust is now in the position of needing to win them back to survive both clinically and financially. The only way it can succeed is if it can match the wait times the private sector are offering. To do this it needs more capacity – more beds, more staff, enough theatres to prevent elective cancellations.

What is the CCG doing to enable our hospital to survive the impact of the MSK contract?

The CCG is working with BSUH and SMSKP to improve the information given to patients, which will highlight the benefits of receiving their care at BSUH and this is expected to increase the numbers of patients seen at BSUH. We are pleased to report that BSUH currently offers patients very similar waiting times compared to their local independent providers.

Patient choice is a national policy and an NHS Constitutional right of the individual which sits outside the authority of the CCG. However the CCG is certainly applying its best endeavours through joint working with BSUH to mitigate the impact of this policy on the sustainability of the Trust as a key local partner in delivery of health services.

If the CCG is not able to mitigate the detrimental effects should the contract be cancelled?

The services provided under the contract have achieved significant successes both in terms of improving the quality of care provided to patients and in terms of managing the overall demand for services within an affordable and manageable level. This has also resulted in a reduction in waiting times for patients, partly through ensuring that patients are fully involved in a shared decision-making process to support them in making positive choices about their treatment plans.

Indeed the service has received a HSJ award in recognition of the innovation used in its shared decision-making function.

Patient choice is a requirement on the NHS for all patients regardless of the contracting framework in place and there are numerous examples in other areas of the country of patients exercising this right to choice.

Taking these facts into consideration and the fact that the MSK Central contract covers the populations of Brighton and Hove and also of Crawley and Horsham and Mid Sussex, termination of the MSK contract would result in a significant loss of benefits to the quality of patient care yielded through that contract, with no obvious benefits to either patients or to local NHS organisations accrued as a result.

We are committed to working with BSUH and SMSKP to explore new ways of working that will improve pathways of care for patients and ensure sustainability of services into the future.

Item 16.3.3

Question was withdrawn by the author.

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Item 16.3.4

Brighton and Hove CCG

Response to Petition:Brighton General Hospital Action Group: statement and questions to CCG accompanying presentation of petition (Stop the Theft of Brighton General Hospital site: Keep it Public.) CCG meeting 07.08.19.

To be read by the CCG Clinical Chair:

Thank you for presenting the statement and questions from Brighton General Hospital Action Group, and accompanying petition in relation to Brighton General Hospital, to the CCG Governing Body.

The statement and questions relate to the provision of community beds-based care within Brighton and Hove including the use of spot-purchase beds, the plans of the CCG for community beds in the city and the decision not to commission community beds on the Brighton General Hospital site.

The BGH Action Group has highlighted in its statement the CCG’s use of ‘Spot Purchase Beds’ to provide a setting for a person coming out of hospital who is not well enough to return to their usual residence. Spot Purchasing of beds is a practice only used in extreme circumstances when no other local capacity is available. Due to the higher cost of these beds, it is rare now for the CCG to use them. There have been no spot-purchased beds used since February 2019.

The action group has also raised the issue of Delayed Transfers of Care from hospital and Stranded Patients. In 2016 the percentage of discharges from the Royal Sussex County Hospital which were delayed was around 12%, which placed Brighton and Hove as a national outlier. Over the course of the last 24 months, the CCG has overseen significant transformation in this area, working in partnership with the hospital and community health provider, the City Council adult social care team, and the community voluntary sector.

Today, discharges that are delayed make up less than 3.5% of all discharges and with further transformation plans and investment underway it is expected for this trend to continue. The CCG will continue to work in partnership with patients and all stakeholders to improve on this even further.

Stranded patients are people who have been in hospital for more than 21 days. Sometimes there is a clinical justification for this, such as someone who has a serious illness requiring long-term hospital treatment, or someone who is recovering from a serious accident. However some stranded patients are ready to leave hospital but are delayed because they have complex needs. It takes time to arrange suitable packages of care in the community to ensure people with complex needs are well looked after when they leave hospital and continue to improve in their health and wellbeing.

Unfortunately, this can sometimes lead to delays in helping a person to leave hospital. It is very rare in Brighton and Hove that a delay to discharging a stranded patient from hospital is due to availability of community health beds, and more usually it is because they are awaiting longer-term residential or domiciliary care. System partners are working together on our ongoing long-

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length-of-stay review and we make stranded patients a daily focus of our clinical and leadership teams.

The action group have raised a question about the availability of Community Intermediate Care Facilities in Brighton and Hove and have sought clarity from the CCG on what community beds are available in the city and what future plans are. The statement also highlights the Brighton General Hospital redevelopment proposals, and asks why this site was not chosen by the CCG to provide community beds.

Following the changes to admission criteria at Knoll House and Craven Vale, which are two City Council Care Homes in the City, the CCG have commissioned a new model of community beds in Brighton and Hove which not only increases the overall number of community beds for our residents, but also provides a significantly enhanced level of care compared to previous provisions. This is part of a wider long-term investment programme into community health and care services.

These changes are in response to the emerging health needs of our population and the increase in health and care needs for patients leaving hospital. The commissioning plans have also given detailed consideration to the feedback given by patients captured in a February 2019 Healthwatch report into patient experience of being discharged from hospital.

From October the CCG is mobilising:

24 community rehabilitation beds at Lindridge Nursing Home in Hove, run by Sussex Community Partnership Foundation Trust,

16 sub-acute step-down beds at Newhaven Community Hospital (in Newhaven), run by Brighton and Sussex University Hospitals NHS trust

12 specialist 24-hour nursing home beds to support patients with dementia or who are unable to walk unaided, provided by independent nursing homes.

These 52 new beds are in addition to the existing community beds based at Ireland Lodge and Wayfield avenue nursing homes and Lewes, Uckfield and Crowborough Community Hospital which in total provide 174 community beds for our local residents.

A number of sites to provide these beds were considered by the CCG, including Brighton General Hospital. Due to the significant age and deteriorating condition of the building at Brighton General, the CCG determined at an early stage that the estate is unfit to provide the level of care and positive patient experience desired. The CCG determined that the level of public resource required to return the estate to a suitable condition and to construct the necessary community ward areas could not be a justifiable use of public funds, given that alternative suitable facilities already exist within the city.

The CCG will continue to develop and enhance the health and care services provided for our residents, working in partnership through continued public and patient engagement. Through continued investment in community services, we are responding to population health data and patient feedback to develop our community health services further to support more people at home and avoid unnecessary admissions to acute and community hospitals.

END.

Footnote: A revised petition was received after the response had been prepared however it was felt that this response still addressed the points raised in the original petition statement. If the

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group wished a discussion on this, as requested in their revised petition statement, they were invited to arrange this post meeting but it was not possible to have this discussion at this meeting.

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